You have been asked to prepare a reference guide about reimbursement concepts that can be used as a reference for yourself in the future.
Assessment Preparation
As you research and prepare for this assessment, review the following resources:
NHA Study Guide Module 2:
Verifying Insurance Eligibility and Benefits
Financial Considerations
Medical Insurance: A Review Cycle Process Approach:
Ch. 1: Introduction to the Revenue Cycle
Section 1.8: The Revenue Cycle
Ch. 8: Private Payers/ACA Plans
Section 8.6: Participation Contracts
Assessment Deliverable
Create a 700- to 1,050-word reference guide using headings, bullets, calculations/visuals, and paragraphs that includes the following information:
Reimbursement Process
List the 11 steps of the NHA reimbursement process.
Eligibility
Explain why verifying a patient’s eligibility with their health care plan is important to ensure reimbursement. Include what could possibly happen if this step is missed or skipped.
Describe the importance of verifying the provider’s participation status with the patient’s health plan. Include what could possibly happen if this step is missed or skipped.
Referrals/Authorizations
Define both referrals and authorizations.
Describe the steps for requesting or obtaining referrals and authorizations.
Explain why not obtaining a required referral/authorization could impact reimbursement.
Patient Cost Share Terminology
Explain the difference between a co-payment and co-insurance.
Describe what a deductible is and how it’s used.
Examples of Calculating the Patient and Insurance Portion of Charges
Ex: Dr. Smith bills $250 for an office exam; Jane owes a $25 copayment.
Ex: Dr. Jones bills $600 for an allergy test; Jose owes a 35% coinsurance payment.
Provide a calculation example for each of the following:
Patient’s copayment + insurance portion = full reimbursement
Patient’s coinsurance + insurance portion = full reimbursement
Tips to Prepare Patients for their Upcoming Visit
Describe the information patients need to know about paperwork, finances, etc. before they walk through the door.
Note. You are welcome to use the Reference Template provided or create one of your own.
Include at least 1-2 APA-formatted references.
Submit your assessment.
Resources
Center for Writing Excellence
Reference and Citation Generator
Grammar Assistance
